Coroner's Finding: ZERK Ike Jordan

Contributing factors

• failure to advise cessation of strenuous physical activity after September 2014 echocardiogram despite gradient of 57.7 mmHg exceeding surgical intervention threshold
• failure to ensure September 2014 echocardiogram report and letter reached the Melbourne surgical team
• failure to follow up on December 2013 correspondence that did not reach Melbourne
• lack of systematic follow-up mechanism for inter-hospital correspondence
• failure to communicate the significance of echocardiogram findings to parents
• reliance on ordinary mail service without verification of receipt for crucial clinical data

Coroner's recommendations

1. The Minister for Health should raise the issue of establishing a fixed guideline of 50 mmHg for surgical referral with interstate counterparts to encourage the profession to publish guidelines on this matter.
2. A mandatory system must be instituted for all cardiologists treating paediatric patients requiring registration of patients with the Women's and Children's Hospital and provision of patient data to that hospital. The Women's and Children's Hospital should be responsible for forwarding reports to the Melbourne team when required, ensuring safe transmission of crucial data rather than reliance on ordinary mail service.